Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you use anticoagulation in cancer patients who develop an unprovoked superficial vein thrombosis?
It depends on the extent of the thrombus and clinical circumstances. Superficial vein thrombosis is triggered by the presence of malignancy. For distal minimal symptomatic thrombosis, I would consider time limited anticoagulation. For more proximal and symptomatic thrombosis, I would consider more e...
Do you check beta 2 microglobulin in patients with MGUS?
I think this question can be answered in two ways - firstly, from the vantage point of clinical utility, and secondly, from the vantage point of cost-effectiveness. I think the short answer to both is no. For patients with suspected smoldering MM awaiting bone marrow biopsy, PET-CT, wbMRI, etc. I ...
When patients develop headaches from luspatercept, do they tend to improve over time?
I've seen two common scenarios with this. One is headaches related to hypertension as a result of luspatercept. By treating the hypertension, the headaches often improve. If the headaches are in the absence of hypertension, I do use a low dose beta blocker to see if it helps, and have had some resul...
What precautions do you take prior to CABG in a patient with sickle cell trait?
Surgery and anesthesia are safe in sickle cell trait (HbAS) when normal precautions are followed. In patients with HbAS and control subjects, the frequency of anesthetic, surgical, and postoperative complications was similar; however, most patients were young, and few thoracic procedures were includ...
For T cell ALL treated in CR (without transplant), how often do you do BM biopsies as part of surveillance, and for how long?
The role of surveillance bone marrow exams in ALL (either B or T-lineage) is a matter of some debate. Thoughtful clinicians can disagree, but in my practice, I do NOT routinely perform these procedures, instead reserving them for signs or symptoms suspicious for relapse. This is analogous to how the...
How do you approach a cervical node biopsy-proven follicular lymphoma in situ in a symptomatic patient with night sweats and PET findings of low SUV uptake throughout the body?
Follicular lymphoma in situ, aka in situ follicular neoplasm (ISFN) is an uncommon entity, representing an early precursor lesion and better conceived of as premalignant as opposed to a true malignancy, and a pathologic diagnosis of ISFN is not an indication for therapy. Most patients with ISFN will...
What are the best labs to trend improvement in HLH?
Unfortunately, there is not one specific laboratory test to definitively trend responses to HLH directed therapy. In general, our approach is to obtain baseline inflammatory labs including CBC with differential, ferritin, soluble IL2 receptor (sIL2r), triglycerides, coagulation studies (PT/PTT) incl...
How do you perform fertility counseling for a patient with a duplication of one of the alpha genes and their partner who has a beta chain point mutation?
There is a 25% chance that a fetus would inherit the alpha-globin genotype ααα:αα and a 25% chance of inheriting the beta-globin genotype βT:β. One family study suggested that the compound heterozygous genotype ααα:αα/βT:β had no clinical manifestations and resembled beta-thalassemia trait. (1) Howe...
Would you recommend adding a TKI to a pediatric regimen for a AYA B-ALL patient with IKZF1 mutation?
I would not add a TKI to standard chemotherapy in this situation. Background/Rationale: IKZF1 mutations (specifically deletions) are associated with inferior prognosis. Specifically, the prognosis appears to be worst with mutations that lead to loss-of-function (e.g., focal deletions [Beldjord et al...
How do you mitigate 6-MP-induced GI toxicity in pediatric and AYA patients with leukemia?
This is a great question as GI toxicities are commonly encountered in children, adolescents, and young adults being treated with 6MP including elevated transaminases, pancreatitis, and hypoglycemia. These GI toxicities are likely due to a skewing of 6MP metabolites with an accumulation of the GI tox...